Home Walking Program Eases Peripheral Artery Disease Limitations

Motivating patients with peripheral artery disease (PAD) and intermittent claudication to start walking at home improved their exercise capacity, the MOSAIC trial showed.

Six-minute walk distance improved by 16.7 m more with the physical therapist-led intervention compared with usual care alone at 3 months (from 352.9 m at baseline to 380.6 m vs 369.8 to 372.1 m, P=0.009), reported Lindsay Bearne, PhD, of King's College London, and colleagues in JAMA.

The effect was "modest but clinically meaningful," commented Mary McDermott, MD, of Northwestern University in Chicago, in an accompanying editorial.

Other randomized controlled trials have shown larger effects from home-based walking exercise interventions for people with PAD, with 45- to 53-m improvements over the control group.

Bearne's study, with just two 60-minute one-on-one sessions in-person with a physical therapist during the first and second weeks and two 20-minute phone calls at weeks 6 and 12 of the 12-week intervention, "included fewer in-person visits and did not objectively monitor intensity of walking exercise, which may have lessened the potency of the home-based exercise intervention," McDermott noted.

Supervised exercise therapy -- typically using a treadmill at a healthcare facility in the presence of an exercise physiologist or nurse -- has been a staple of care for lower-extremity PAD for decades, and it's covered by Medicare. However, most patients don't participate in these programs, McDermott wrote.

"A highly effective home-based exercise program has the potential to help millions of people with PAD, including those in rural areas without access to supervised exercise therapy and those unable to travel regularly to the facility to participate," she concluded. "By avoiding the need for an exercise facility or a coach during each exercise session, home-based exercise programs are likely to be less costly than supervised exercise."

"Given the absence of alternative highly effective noninvasive therapies for PAD, developing home-based exercise into first-line therapy for PAD is an imperative," she added.

The trial included 190 patients with stable symptoms of clinician-diagnosed PAD and intermittent claudication recruited from vascular clinics in six U.K. hospitals from January 2018 to March 2020.

Participants were randomized to usual care or the interventions, delivered by physical therapists using a "motivational interviewing approach guided by behavior change principles to increase participants' intention and commitment to walking exercise." This entailed helping patients understand PAD, setting individualized and progressive goals for walking (at least 30 minutes a day three times a week, at a pace that would elicit moderate leg symptoms), monitoring their progress in that regard, and identifying and overcoming challenges to stick with their walking plan.

The intervention led to greater perceived walking ability at 6-month follow-up as compared with usual care (between-group difference in score on the 100-point WELCH scale 7.4, P=0.003) and improved perception of their illness (Brief Illness Perceptions Questionnaire score difference -6.6, P<0.001), as well as attitude score (between-group difference 1.4, P=0.02).

No differences were seen in quality of life, self-reported maximum walking distance, activities of daily living, or perceived behavioral control and intentions about walking.

No serious adverse events were deemed related to the intervention. The same number of falls occurred in each treatment group (three each).

Social restrictions during the COVID-19 pandemic might have been a barrier to planned walking, Bearne and team noted. "However, most participants completed the primary outcome prior to the start of the pandemic," they wrote.

Study limitations included the large loss to follow-up, with 22% of patients not returning for the 6-minute walk test. Although the researchers suggested this had a "negligible" impact on the trial's statistical power, "participants without 6-minute walking distance at follow-up had a lower baseline 6-minute walking distance than those with the primary outcome."

Also, most of the participants were white men, limiting generalizability, and the follow-up period was relatively short.

"Further research is needed to determine the durability of these findings," Bearne and colleagues wrote.

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